This survey has shown a huge gap in the knowledge of Nigerian doctors, in general practice, on the management of asthma patients. It shows that despite the availability of effective therapies and development of international guidelines to assist in the management of asthma patients, the prescribing practices of many of the doctors do not conform to internationally recommended guidelines. This finding is in agreement with previous studies in other countries, which have revealed a poor quality of drug prescription for asthma by doctors.[6
Over 75% of the doctors reported that they usually prescribed IV methylxanthines for patients with acute severe asthma. This was sometimes prescribed in combination with oral or inhaled SABA by the doctors. This practice was in sharp contrast to the international guidelines.[1
] Although methylxanthines were once a standard treatment for asthma in an emergency, it is now known that their use increases the risk of adverse events, without improving the outcomes. They were only recommended if inhaled SABA was not available.[1
] In spite of these and other evidences that IV methylxanthines are less effective than inhaled SABA,[13
] IV methylxanthines are still commonly used in emergency treatment of asthma even in combination with SABA. As they were prescribed with SABA by 56.3% of the doctors, it meant the doctors did not prescribe it because SABA was not available. Oral SABA was also commonly prescribed by the doctors. Oral administration of SABA was not recommended, as it had not been shown to be more effective than inhaled SABA and was associated with an increased frequency of side effects.[15
In tandem with the international recommendations, systemic steroids were commonly prescribed for acute severe asthma by more than 90% of the doctors. However, almost 60% of them prescribed the IV formulation rather than the recommended oral steroids. The routine use of IV steroids would increase the cost of treatment and produce unwanted adverse effects, without any significant advantage over the oral steroids. On the other hand, the oral steroid was usually preferred in the absence of contraindications, because it was equally effective and less invasive.[16
] Other agents like antibiotics, antihistamines, and mucolytics, which were not routinely recommended for acute exacerbations of asthma[1
] were also prescribed by a quarter of the doctors. These agents increased the cost of prescription, produced unwanted adverse effects, and could delay the use of appropriate therapy.
A disturbing finding in this survey was the common prescription of oral steroids and oral SABA for long-term control of asthma during follow-up visits. Although oral steroids were effective in controlling symptoms and were cheap, their prolonged use could result in serious unwanted effects. Therefore, continuous treatment with oral steroids was generally avoided, except for the most difficult-to-control asthma.[1
] Similarly, the regularly scheduled, daily use of SABA was not recommended, as it had no demonstrable benefits,[17
] and might in fact be deleterious in some patients with asthma. The chronic use of SABA was associated with an increased risk of an acute exacerbation that required an emergency department visit or hospitalization.[18
] Also, a decrease in lung function after stopping chronic use have been reported with a regular use of SABA.[21
A more worrisome finding is the infrequent prescription of ICS (6.6%) and ICS/LABA (15.0%) for a long-term control of asthma, during follow-up visits. Several earlier studies have shown that inhaled steroids with or without inhaled LABA are the medications of choice for persistent asthma, as they are effective and have a low-rate of side effects.[23
] Postma et al
] reported that ICS monotherapy and ICS plus LABA effectively controlled daily symptoms in their asthma patients.
Generally, the cost of drugs does not seem to play a major role in the prescribing pattern of these doctors because only 42 (13.1%) of the physicians reported that that they were guided by cost in their choice of drugs. However, despite the fact that just 13.1% of the physicians were guided by cost, it is important to note that cost significantly influenced drug prescription among private practitioners, rather than those working in public health institutions .
A factor that may explain the poor drug prescription for asthma by the doctors is their low level of participation in the update training on asthma. Almost half of the doctors (47.8%) had never attended any form of update training on asthma, whereas, only 16.3% attended any form of update within the last year preceding this survey. The low level of participation in asthma management programs has been reported in earlier studies.[26
] One possible explanation for the poor participation of the doctors in the training on asthma management is the lack of well-organized, regular, continuing medical education in Nigeria, at the time the survey was carried out. This may explain why 65.6% of the medical officers relied on what they had learnt in medical school in the treatment of their patients, several years after graduation. We hope that this trend will change with the recent introduction of continuing medical education credits by the Medical and Dental Council of Nigeria for the renewal of practicing license with effect from year 2012.
Another equally important finding that may further account for the poor prescribing pattern of the doctors is their poor awareness of the international guidelines on asthma treatment. Although 110 (34.4%) doctors claimed that their prescriptions were guided by recommendations from guidelines, only a surprisingly low 16.4% of them were able to mention the correct guidelines. This may be related to the lack of locally available national asthma guidelines in Nigeria. Therefore, the Nigerian Thoracic Society should follow the good example set by the Saudi Thoracic Society,[27
] in the development of simple-to-understand, updated national asthma guidelines, for use by the non-asthma physicians. This should be combined with an extensive asthma campaign to popularize the use of the guidelines among our doctors. The impact of such a campaign on physicians’ prescription practices was reported in an earlier study by Al-Shimemeri et al
The interpretation of the results of our study has some limitations. The results reflect the reported prescription of doctors willing to participate in the study. Secondly, due to inadequate resources, we surveyed doctors in the capital cities, thereby leaving out those in the more remote areas. Another limitation is the fact that the states have been selected based on the location of the investigators. These factors would most likely have introduced a selection bias. Another limitation is the fact that the results are based on a self-reported prescribing pattern by the doctors, who may have been biased in their report. Finally, the reported prescribing behavior of the Fellows must be interpreted with some caution, as few of them participated in this study.
In spite of these limitations, this study has shown that poor anti-asthma-prescribing behavior among Nigerian doctors in general practice is associated with the low level of participation at the update training on asthma management, and poor awareness of asthma guidelines. Therefore, the Nigerian Medical Association should expedite action on the development of the recently introduced continuing medical education in the country, while the Nigerian Thoracic Society should urgently develop and circulate widely, national asthma guidelines that are fully adapted to the prevailing situation in Nigeria.[28